chest tube management

[unchartedem]

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If you place a chest tube in someone and it seems to be in place, however post chest tube x-ray still shows persistent PTX, do I need to immediately place a 2nd chest tube or should I give it sometime(24 hours or so) to re-expand with suction? Any help would be appreciated.

 

[cpants]

Depends on how the patient is doing. Symptomatic? Also how big the PTX is. Before you place another tube, you can try to move it -- only by withdrawing and/or twisting, never pushing inward.

 

[SLUser11]

If you place a chest tube in someone and it seems to be in place, however post chest tube x-ray still shows persistent PTX, do I need to immediately place a 2nd chest tube or should I give it sometime(24 hours or so) to re-expand with suction? Any help would be appreciated.

It sort of depends on the reason for the PTX (e.g. trauma vs. iatrogenic vs. spontaneous) as well as the presence or absence of symptoms, presence or absence of air leak, type and quantity of drainage, etc.

Some pneumothoraces don't require a chest tube to begin with, while others need multiple. Some things look like a persistent PTX but are really something else, e.g. bleb/bullous disease. Some lungs are scarred and won't completely re-expand no matter how many tubes you have.

What I've done there is change a simple question into a much more complex question, so I doubt I was very helpful. However, I think it's important to understand all the complexities of chest tubes. Having cookbooks or knee-jerk formulas don't always work.

I think Robert Cerfolio from UAB has written the best stuff about chest tubes. You can do a lit search and find multiple articles, but he also has a review in Surgical Clinics of North America that is good.

 

[turkeyjerky]

here's the pubmed link to that review if anyone's interested. Looks like it was published 10 years ago, any changes in practice since then?

 

[blue2000]

My thought process in an approach to a patient with a PTX that doesn't re-expand with chest tube placement:

1) Is patient stable? If no, I'd be more likely to either reposition the tube or place another one. If yes, I'd be more likely to consider other options. Also, is the chest tube working? Have I run the system? Do they have an air leak? What kind? Is the chest tube really in the chest cavity? I've seen chest tubes that look perfect on portable Xray that are tracking sub cutaneously behind the chest cavity.

2) Is there anything about this patient that would make additional imagine helpful? Age, smoking status, prior lung surgery, etc. may make a CT of the chest helpful, while a straightforward young trauma patient may just need another tube.

3) If it's a trauma patient, am I missing another injury? Do I need to bronch the patient to look for a tracheal or high bronchial injury?

I'm sure if I thought about this more, I'd come up with other thoughts, but these are mine off the top of my head.

 

[dfagod]

The most important thing (aside from the condition of the patient) is if there is an air leak. If the chest tube is actually in good position and functioning properly (not kinked, clogged) I would expect a HUGE air leak if there is persistent pneumothorax.

If there is in fact a huge air leak, placing another chest tube may not help the patient. Depending on the mechanism, they may have a bronchial or tracheal injury. Placing another tube may suck out a large portion of the o2 and may make the patient hypoxic. In this case, sometimes advancing the ET tube beyond the injury may be the most helpful thing you can do.